Friday, February 16, 2018

Clear. Clinical. Documentation.

Bloggers note- we posted this blog almost a year ago to the day. It’s one of those topics that never gets old and the information remains as important as it was the first day we posted it. All of us must keep this important concept in mind when documenting our EMS transports. I hope you enjoy reading it again (or for some of you for the first time!)


Three words with impactful meaning anchor our discussion today. The Center for Medicare and Medicaid Services (CMS) sets the definition of medical necessity of an ambulance patient that all of us in the ambulance billing industry strictly adhere to.

The definition centers on the clinical requirement “where the use of other methods of transportation is contraindicated by the individual’s condition.” The direction we receive from “The Feds” includes the warning that EMS Patient Care Reports (PCRs) must include clear clinical documentation detailing the ambulance transport incident verifying that the patient truly met the clinical requirement.

Thus, once explained in the PCR, Medicare, Medicaid and most other insurance payers will reimburse the claim that your billing office submits for payment to cover the costs for you to provide an EMS service to your patient.

So let’s quickly breakdown our three key words.

Clear. Clinical. Documentation.


The word clear is used as an adjective, adverb or verb. The overriding definition in the dictionary defines the word as denoting transparency or defining something as easy to perceive, understand or interpret leaving no doubt or ambiguity.

The medical necessity definition uses it as an adjective. So, clear clinical documentation calls for the documentation in your PCR to be easily interpretive to describe your patient’s medical necessity leaving no doubt or ambiguity that other methods of transportation were contraindicated (or not) for your patient given the condition they were in at the time of the transport.

It’s a very simple concept when you think about it and yet we, in EMS, struggle with it because many of us are just not good with words.

Remember your PCR does not have to be a best-selling novel, but the words in your PCR must be precise and clearly demonstrate why there was no other way to transport your patient without endangering or further exacerbating the patient’s medical condition.

If there were another way to transport the patient without further endangerment of your patient, then the decision can be made based on the clarity you’ve written into your PCR as to whether it is best to bill to the insurance payer or direct to the patient.


Something is clinical when it coincides with and involves the actual observation and treatment of a patient. Of course we know that payment for ambulance is based on transportation but observation and treatment happens in the transporting ambulance, so the two go together.

This is where the focus of your documentation is placed.

When we are directed to support medical claim billing for ambulance transports by providing clear clinical documentation in the PCR, the clinical part calls for EMS providers to document that observation and treatment in such detail that it paints a picture in words regarding everything that happened on the scene, in the ambulance during transport and upon arrival at the facility leading to patient transfer.

Clinical is objective. Clinical involves numbers, readings and interpretations such as vitals with numeric values, readings from medical instruments in the ambulance with accompanied objective and scientific interpretations of the instruments’ values. The result is written statements about the patient’s medical condition such that the reader of your documentation clearly has a laser view into the patient’s condition in that moment of time.

It’s clear that the authors of the ambulance medical necessity definition were anticipating that every single ambulance transport that is billed for reimbursement will be supported by a PCR that is written in adequate detail to spell out the clinical relevance of the incident.


And finally after two adjectives, we arrive at the noun to anchor the phrase.

Documentation is official information and/or evidence that comprises a record of an event or happening. We use documentation to classify (such as choosing a procedure code to denote the ambulance level of care- ie. Emergency vs. Non-Emergency, ALS vs. BLS, etc.)

We also use documentation to support the all-important ICD-10 diagnosis code that spells out the patient’s condition at the time of transport. Here text is primarily used to describe the patient’s condition and chisel in time the definitive historical clinical record of this one ambulance event.

Because the documentation is clear and clinical, the reader will be able to review the PCR and gain a full understanding of why this patient, in this moment of time used the ambulance for transport from one place to another in either an emergency or routine non-emergency event.

Friday, February 9, 2018

Congressional Victory- Medicare Add-Ons Receive New Life!

Minutes Ago…

We’re writing this piece on the morning of Friday, February 9, 2018. Remember this day, as just minutes ago the United States Congress passed a bill to keep the government’s doors open for another month and with it they passed important provisions affecting the ambulance industry.

Congressional Victory- Medicare Add-Ons Receive New Life!
Literally hours after Congress approved the measure, the President signed it into law.
Congress just passed a 5-year extension of the Medicare ambulance add-on payments!

The American Ambulance Association issued a quick notice to the industry celebrating this passage which was part of a two-year budget deal reached by congressional leaders and finally passed by the Senate early this morning and ratified by a favorable vote in the House of Representatives soon thereafter.


By now, most everyone recalls that over fifteen years ago it was determined that the Medicare National Ambulance Fee Schedule was underfunding the ambulance industry by a pretty wide margin. At the time, Congress decided to put in place a “temporary” stop-gap measure that amounted to an add-on payment factor of +2% for urban area reimbursements, +3% in rural areas and +22.6% in the most remote geographical areas designated as super-rural. Additionally, in the rural and super-rural areas per mile reimbursements were increased by an additional 50% for the first 17 loaded mileage of each transport.

The catch was that each year these add-ons had to be renewed by Congress. After a while, Congress extended the add-ons for a period of multiple years with the last extension expiring on December 31, 2017 with no action to extend decided by Congress prior to expiration of the current term.

Lobbying groups like the AAA pushed hard for the reinstatement of the add-ons and finally, today, those efforts paid off. The industry anticipates that these add-ons will be made retroactive back to January 1st and applied to payments moving forward.

In Exchange

In exchange for conceding a 5-year extension which costs additional Medicare dollars, Congress placed some future conditions on releasing the purse strings.

Cost Data Collection

This was inevitable.

Congress needs to be supplied proof that we deserve these extra dollars. So, for the first time in our history, the ambulance industry will be required to submit periodic Cost Data reports to CMS.

The good news is that the ambulance industry will have direct input on the structure and implementation of the Cost Data report. This is a concession brokered by the AAA so there is input from our side. Congress is requiring this so there is an “appropriate balance” between obtaining useful data without overburdening or “onerously penalizing” ambulance services.

However, it is written into the provision that there will be a 10% reimbursement deduction penalty assessed in each year following an ambulance service’s failure to report cost data when requested. This is considerably a better option than the original plan of taking payments back or an outright withholding of payments which was on the table in the first draft of the legislation.

Additional Cuts in Dialysis Transports

In order to pay for the extension, Congress will assess an addition 13% reimbursement deduction to non-emergent dialysis transports. Again, this is a reduction from the 22% proposal in the first draft.

Of course, this adds the 10% reduction from a few years ago that is already in place.

While unfortunate, we all know that dialysis transports are continually on the radar screen for the Feds and the target of many a fraud and abuse investigation. So, it comes as no surprise that this provision rides in on the coattails of the extension legislation.

President Signed Immediately!

Literally hours after Congress approved the measure, the President signed it into law. Now, some administrative formalities will take place in order to implement the changes. We hope to see CMS release a Public Use File (PUF) listing the new reimbursement fee schedule in the days coming.

Friday, February 2, 2018

The “Face” of Your EMS


Whether you realize it or not, the EMS agency you serve has a face and it’s you!

It’s the impression that is left behind in the eyes of the patient, his/her family and/or the people that surround him including, by extension, facility staff and those in the overall care loop.

The “Face” of Your EMS
Your EMS agency’s face is very important as it ultimately becomes how it represents and labels you to the patients in the communities you serve.

Let’s take a look at the three areas that make up our EMS agency footprint.

Intake/Front End

The very first encounter outsiders have with your agency is when the phone rings, so the call intake portion at the front end of your process is extremely important for setting the tone of what your agency’s customer service face looks like.

If your agency is a 9-1-1 provider, this is beyond your control- or is it?

As an administrator, have you met recently with the persons in charge at the 9-1-1 center to take a look at what they do for you? Sometimes simple dialogue can help each side understand each other better, plus it opens up channels for you to examine how your agency is being represented to the public.

If your agency handles routine, non-emergency transports it’s likely you maintain a separate call intake resource outside of the 9-1-1 system. Here’s where your agency’s customer service face is crucial.

Not only does call intake drive your agency by pulling in work on any given day, but the encounter experienced by the patient and the facilities you serve may dictate whether or not your agency is used by the referral source for future transports.

Plus, your call intake staff helps with all phases of the transport scenarios by obtaining vital information that is helpful to your street staff all the way through the back end of your process, flowing to the billing office and collection success.

Street Presence- Reacting and Interacting

Administrators… How are your crew members representing your agency? Do you know?

EMS providers… How are you representing your agency? Do you care?

Notice we’re addressing two groups of people here. It’s important that as an administrator, you have boots on the ground in some form in order to have a handle on how your crews represent your agency out there where it happens.

As EMS providers, you and your partner must remember that your agency’s reputation and ultimately your reputation rests on your shoulders and how the patient public sees you react and interact.

How do you look today? What are you saying today? If you love your job, show it by treating people with the same caring mannerisms you’d want someone to treat you with if you were the one lying on the stretcher.

If you hate your job, find another one.

Closing the Loop- The Back End

The run’s completed and your patient has been delivered to his/her destination.

How is your agency represented by the office, following the run? 
Specifically, since this is a blog centering on EMS billing; how is your agency represented by the billing office?

Whether your agency maintains its own hired staff for billing or you use an outsourcing agent for the task, once again the “face” the patient will remember will be that of the person who answers the phone and guides your patient through the revenue recovery cycle.

Staff members who practice good phone etiquette and are trained in being professional and courteous will win the day for you. As an EMS billing outsource company, we argue that professional customer service trained individuals who do nothing but this all day long can be the consistent positive face for you. These people must be adept at problem resolution, have a high level of compassion and knowledge and understand all phases of EMS billing.

The Right Step

Now it’s time to take some steps to adjust your agency’s face. Do the following…
  • Review- take a good look at your EMS agency’s face at all levels. 
  • Analyze- identify the good faces and the not-so-good faces of your organization.  Survey, ask your patients questions, test and measure
  • Act- excise the parts of your face that are less than positive, replace and retool where possible but also reinforce the areas that are working.
    • Consider outsourcing and consulting- there’s someone out there that can give you a softer and more effective face!

Friday, January 26, 2018

The Power of a Beginner’s Mindset

This week…

This week several of us in the billing office had the pleasure of taking a day to re-evaluate our leadership skills.

Business coach Jim Riviello of Leadership X University, author and business motivator, spent a memorable day with us as we examined our impact on the EMS billing industry basically from the inside out.

Part of our day centered on approaching our duties from a beginner’s mindset.

What if it isn’t?

If you are open to new ideas then you most likely have harnessed the power of the beginner’s mindset. Think back to when you were brand new to EMS and how your mind was asking questions every 5 seconds.

The Power of a Beginner’s Mindset
But now that you are not a chronological beginner, are you a mental beginner? If you have the beginner’s mindset then you’ll be eager to re-think every single process you own.

What you have been taught to believe may be true- but WHAT IF IT ISN’T?

As we worked through applying this to our EMS billing world, the concept not only relates to the office but also to many aspects of this life-saving thing that we do on the outside in the field, too.

We encounter people we work with all the time that are dug in and very much a creature of habit- even to the point of protecting processes just for the sake of protecting them. We all know that in EMS in order to be effective we must continually question our practices and the things we do every day.

Had we not questioned the things we do over the course of many years, we’d all be running around in a Cadillac with nothing more than a scoop stretcher and an oxygen tank.

The same holds true inside, too.

There’s no way that we can navigate the EMS billing world using the same tactics and routines of even just a few years ago. Times change and we must adhere to the following steps in everything that we do in EMS.

Ask More Questions

Think about it, asking questions is at the center of EMS.

If you are good fashioning effective questions then you’ll be good at assessing your patient, good at treating your patient, and by extension good at documenting your run effectively too.

Then the EMS agency you serve will be well-served.

Foster an environment within your EMS agency where asking questions are center to the culture. Stale ideas and the inability to ultimately change will torpedo our systems.

I think our billing office is really good at asking questions. Is your’s?

We look to test, measure and tear it all apart if needed because we must serve our clients and the communities they serve in order to bring in every dollar to save the next patient’s life.

Welcome and Embrace Change

When ICD-10 was mandated on October 1, 2015, few billing offices (ours included) were doing anything but “embracing” change. We all were grumbling and fiddling with our billing systems to accommodate the new mandate.

We made it happen because we had to make it happen. But embrace it? Probably not and simply because it was CHANGE (big change!)

Two years later this is the one example that still sticks in our heads because it was personally painful. Change often is painful, but then again so rewarding.

To embrace change is to welcome it. To embrace change is to promote it, teach it, let it grow and weave like a vine into every thread of your EMS agency’s culture…from the street to the office.

The opposite of embracing change is fearing change. When the fear of change invades an organization, like a cancer it chokes off the life of that organization. No one is motivated to find new answers. The same old thing is done day-in and day-out. Performance suffers and morale dips.

Ultimately not much energy flows. Only entropy reigns.

Open to Help and Assistance

We all must continually learn each day.

Our office is learning all the time.

We achieve better results when we share our thinking.

EMS is a team effort.

The providers can’t do their jobs without the mechanic that keeps the truck running. The administration can’t manage the organization without the insights and respect of the people that make up the system.

The billing office can’t bill without precise, detailed documentation from the providers. Likewise if the billing office doesn’t do everything in its power to bring in the biggest buck, then the street providers won’t be paid and the equipment will become dated and ineffective.

Release Past Limiting Beliefs

You must empower yourself and others in your organization to help you create the future of EMS, rather than to hang onto the “glory days” of the past.

So when the billing office asks everyone to get together for some documentation training, be available to join in the discussion. Likewise, if your billing office is demanding things from you that you know will not serve the organization well, then ask the question Why?

Approach your EMS world like you did when you were a beginner and you’ll be surprised at the potential you uncover!